Renal replacement therapy in Europe: a summary of the 2011 ERA-EDTA Registry Annual Report

OUP accepted manuscript

The year 2021 was the last full year of Alberto Ortiz’s editorship at Clinical Kidney Journal (CKJ). On May 2022, Maria José Soler will start her term as the Editor-in-Chief. Over these years, CKJ obtained its first journal impact factor and has consolidated its position among the top journals in the field, consistently ranking among the top 25% (first quartile) journals in Urology and Nephrology. The 2020 journal impact factor rose to 4.45, becoming the top open access journal in Nephrology and the ninth ranked Nephrology journal overall. We now review the recent history of the journal and the most highly cited topics which include the epidemiology of kidney disease, chronic kidney disease topics, such as the assessment and treatment of chronic kidney disease, onconephrology, cardionephrology, glomerular disease, transplantation and coronavirus disease 2019 (COVID-19).

"Together We Stand": A Pilot Study Exploring the Feasibility, Acceptability, and Preliminary Effects of a Family-Based Psychoeducational Intervention for Patients on Hemodialysis and Their Family Caregivers

This pilot study aimed to assess the feasibility, acceptability, and preliminary effects of a family-based psychoeducational intervention for patients undergoing hemodialysis (HD) and their family members. This was a single-group (six dyads), six-week, pre–post pilot study, delivered in a multifamily group format. Feasibility was based on screening, eligibility, content, retention, completion, and intervention adherence rates. Acceptability was assessed at post-intervention through a focus group interview. Self-reported anxiety and depression and patients’ inter-dialytic weight gain (IDWG) were also measured. The screening (93.5%), retention (85.7%), and completion (100%) rates were satisfactory, whereas eligibility (22.8%), consent (18.4%), and intervention adherence (range: 16.7–50%) rates were the most critical. Findings showed that participants appreciated the intervention and perceived several educational and emotional benefits. The results from the Wilcoxon Signed-Rank Test showed that a significant decrease in anxiety symptoms (p = 0.025, r = 0.646) was found, which was followed by medium to large within-group effect sizes for changes in depression symptoms (p = 0.261, r = 0.325) and patients’ IDWG (p = 0.248, r = 0.472), respectively. Overall, the results indicated that this family-based psychoeducational intervention is likely to be feasible, acceptable, and effective for patients undergoing HD and their family caregivers; nonetheless, further considerations are needed on how to make the intervention more practical and easily implemented in routine dialysis care before proceeding to large-scale trials.

Single antigen testing to reduce early antibody-mediated rejection risk in female recipients of a spousal donor kidney

Female recipients of a spousal donor kidney transplant are at greater risk of donor-specific pre-immunization, which may increase the risk of acute antibody-mediated rejection (ABMR). We assessed the incidence of early ABMR (within two weeks after transplantation), risk factors for ABMR and graft function in 352 complement-dependent cytotoxicity test-negative LURD transplant recipients, transplanted between 1997 and 2014 at the Leiden University Medical Center in The Netherlands. Risk factors for immunization were retrieved from the health records. As methods to screen for preformed donor-specific antibodies (pDSA) have developed through time, we retrospectively screened those with ABMR for pDSA using pooled-antigen bead (PAB) and single-antigen bead (SAB) assays. The cumulative incidence of rejection in the first six months after transplantation was 18% (TCMR 15%; early ABMR 3%). Early ABMR resulted in inferior graft survival and was more common in women who received a kidney from their spouse (10%) than in other women (2%) and men (<1%). The SAB assay retrospectively identified pDSA in seven of nine cases of early ABMR (78%), while the PAB detected pDSA in only three cases (33%). Seeing that early ABMR occurred in 10% of women who received a kidney from their spouse, a SAB assay should be included in the pre-transplant assessment of this group of women, regardless of the result of the PAB assay.

International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in Western Europe

Populations in the high-income countries of Western Europe are aging due to increased life expectancy. As the prevalence of diabetes and obesity has increased, so has the burden of kidney failure. To determine the global capacity for kidney replacement therapy and conservative kidney management, the International Society of Nephrology conducted multinational, cross-sectional surveys and published the findings in the International Society of Nephrology Global Kidney Health Atlas. In the second iteration of the International Society of Nephrology Global Kidney Health Atlas, we aimed to describe the availability, accessibility, quality, and affordability of kidney failure care in Western Europe. Among the 29 countries in Western Europe, 21 (72.4%) responded, representing 99% of the region's population. The burden of kidney failure prevalence varied widely, ranging from 760 per million population (pmp) in Iceland to 1612 pmp in Portugal. Coverage of kidney replacement therapy from public funding was nearly universal, with the exceptions of Germany and Liechtenstein where part of the costs was covered by mandatory insurance. Fourteen (67%) of 21 countries charged no fees at the point of care delivery, but in 5 countries (24%), patients do pay some out-of-pocket costs. Long-term dialysis services (both hemodialysis and peritoneal dialysis) were available in all countries in the region, and kidney transplantation services were available in 19 (90%) countries. The incidence of kidney transplantation varied widely between countries from 12 pmp in Luxembourg to 70.45 pmp in Spain. Conservative kidney care was available in 18 (90%) of 21 countries. The median number of nephrologists was 22.9 pmp (range: 9.47-55.75 pmp). These data highlight the uniform capacity of Western Europe to provide kidney failure care, but also the scope for improvement in disease prevention and management, as exemplified by the variability in disease burden and transplantation rates.

Improvement of clinical outcomes in dialysis: No convincing superiority in dialysis efficacy using hemodiafiltration vs high-flux hemodialysis

Hemodiafiltration (HDF) is not associated with lower mortality risk compared to standard hemodialysis (HD). However, there are many critical clinical outcomes in dialysis patients in addition to mortality; the impact of HDF on these other outcomes is not clear. This retrospective study included all patients referred to DaVita Clinics in the Kingdom of Saudi Arabia. High-flux HD was the initial modality in all patients. Those who did not achieve adequacy targets or those with poorly controlled phosphorus were switched to postdilution HDF using 18 to 23 L exchange per treatment. Patients dialyzing with a central venous catheter, patients who dialyzed less than 90 days at DaVita, and those with interrupted HDF were excluded. Of the 1115 patients, 215 (19%) were on HDF and 900 on high-flux HD; the median follow-up was 6 months for all patients. The HDF group showed a significant reduction in serum phosphate (P < .001), a significant increase in serum calcium (P < .012) and a significant improvement in Kt/V (P < .0001). The HDF group had significantly higher hemoglobin levels than the HD group (P = .024), with a significant reduction in weekly erythropoiesis-stimulating agent dose after starting HDF (P < .001). A modified protocol that included prolonged dialysis duration, larger-sized dialyzer, faster blood flow rates, and adding hemofiltration fluid may be helpful in achieving the recommended targets. Thus, HDF can enable the achievement of adequate dialysis care in some patients. Randomized-controlled clinical trials are necessary to confirm these findings.

The Long Road to the Development of Effective Therapies for the Short Gut Syndrome: A Personal Perspective

The ability to provide parenteral support represents a revolutionary change in medical therapy for patients with temporary and inadequate intestinal absorptive capacity or for patients with chronic intestinal failure due to digestive diseases. Nevertheless, due to the rarity of intestinal failure, a de facto policy of "discrimination by organ failure treatment" exists in many countries whereby this problem is under-recognized and under-treated. With the increasing recognition of the pathophysiological consequences of intestinal resection and the occurrence of new pro-adaptive treatments for patients suffering from short bowel syndrome, this review reflects on the history of developments in this area and discusses current practice and future directions of the field.

Diferenças e desigualdades no acesso a terapia renal substitutiva nos países do BRICS

Resumo A doença renal terminal (DRT) é um importante problema de saúde pública, sobretudo nos países em desenvolvimento, em vista dos altos recursos econômicos necessários para manutenção dos pacientes nas diversas formas de terapias renais substitutivas (TRS) existentes. O objetivo deste artigo é analisar as diferenças e as desigualdades que envolvem o acesso a TRS nos países que compõem o BRICS (Brasil, Rússia, Índia, China e África do Sul). Estudo aplicado, descritivo, transversal, qualitativo e quantitativo, com análise documental e pesquisa bibliográfica, tendo como fonte de dados censos nacionais e publicações científicas envolvendo o acesso a TRS em tais países. Verificou-se evidências de iniquidade no acesso a TRS em todos os países do BRICS, ausência de censos de diálise e transplante nacionais (Índia), ausência de legislações efetivas que inibam a comercialização de órgãos (Índia e África do Sul) e uso de transplantes de doador falecido de prisioneiros (China). A construção de mecanismos que promovam compartilhamento de benefícios e de solidariedade no campo da cooperação internacional na área da saúde renal passa pelo reconhecimento das questões bioéticas que envolvem o acesso a TRS nos países do BRICS.

Hypomagnesemia and cause-specific mortality in hemodialysis patients: 5-year follow-up analysis

INTRODUCTION

The aim of this prospective study was to evaluate the association between serum magnesium (Mg) and mortality, in particular the cause-specific mortality of Mg and other risk factors in hemodialysis (HD) patients.

METHODS

We studied a cohort of 185 HD patients receiving thrice-weekly HD treatment, on a dialysate Mg concentration of 0.5 mmol/L. We stratified 3 patient groups according to the level of Mg: lower (<1.1 mmol/L), intermediate-reference (1.1 to <1.3 mmol/L), and higher (Mg >1.3 mm/L).

RESULTS

During the 5-year follow-up, 60 patients died, with cardiovascular (CV) disease as the predominant cause (73.3%). Hazard ratio (HR) for all-cause and CV mortality were 2.55 and 2.67 in the lower versus intermediate Mg group, but there was no significant association between the higher and intermediate Mg group. Univariate Cox regression analysis showed that Mg <1.1 versus 1.1-1.30 mml/L with HR 2.34, was a significant univariate predictor for increased mortality in addition to the Hb <110 g/L, Alb <40 g/L, C-reactive protein (CRP) ≥10 mg/L and brain natriuretic peptide >1,200 pg/mL. However, in the multivariate analysis only CRP ≥10 mg/L with HR 3.89 was a significant predictor of mortality. Subgroup analyses showed that among patients with CRP >10 mg/L, HR for all-cause and CV mortality of the lower versus intermediate Mg group were 1.96 and 2.39, respectively, not reaching significance for the higher versus intermediate Mg group. Conversely, there was no association between Mg level and all-cause and CV mortality within these 3 groups among patients with CRP <10 mg/L.

CONCLUSIONS

Lower serum Mg level was significantly associated with an increased all-cause and cardiovascular mortality in HD patients, especially in inflamed patients.

The Need for New Donor Stratification to Predict Graft Survival in Deceased Donor Kidney Transplantation

PURPOSE

The aim of this study was to determine whether stratification of deceased donors by the United Network for Organ Sharing (UNOS) criteria negatively impacts graft survival.

MATERIALS AND METHODS

We retrospectively reviewed deceased donor and recipient pretransplant variables of kidney transplantations that occurred between February 1995 and December 2009. We compared clinical outcomes between standard criteria donors (SCDs) and expanded criteria donors (ECDs).

RESULTS

The deceased donors consisted of 369 patients. A total of 494 transplant recipients were enrolled in this study. Mean age was 41.7±11.4 year (range 18-69) and 273 patients (55.4%) were male. Mean duration of follow-up was 8.8±4.9 years. The recipients from ECD kidneys were 63 patients (12.8%). The overall mean cold ischemia time was 5.7±3.2 hours. Estimated glomerular filtration rate at 1, 2, and 3 years after transplantation were significantly lower in ECD transplants (1 year, 62.2±17.6 vs. 51.0±16.4, p<0.001; 2 year, 62.2±17.6 vs. 51.0±16.4, p=0.001; 3 year, 60.9±23.5 vs. 54.1±18.7, p=0.047). In multivariate analysis, donor age (≥40 years) was an independent risk factor for graft failure. In Kaplan-Meier analyses, there was no significant difference in death-censored graft survival (Log rank test, p>0.05), although patient survival was lower in ECDs than SCDs (Log rank test, p=0.011).

CONCLUSION

Our data demonstrate that stratification by the UNOS criteria does not predict graft survival. In order to expand the donor pool, new criteria for standard/expanded donors need to be modified by regional differences.

Current trends in European renal epidemiology

The incidence of end-stage renal disease (ESRD) continues to vary substantially between the countries in Europe that contribute data to the ERA-EDTA Registry. Differences can be attributed to socioeconomic factors and prophylaxis programs for patients with chronic kidney disease (CKD) and may also express real differences in CKD incidence. Recently, age-adjusted ESRD incidence has begun to fall in many countries, probably related to improved prophylaxis. However, absolute rates may increase, partly due to socioeconomic advances in countries with a low gross domestic product and partly due to continuing increases in the proportion of elderly patients. Prevalence rates are expected to continue to increase, mainly due to increases in relative transplant prevalence, improved graft survival times and continuing improvements in both dialysis and transplant patient survival. Overall treatment results continue to improve.

The European Renal Association - European Dialysis and Transplant Association Registry Annual Report 2014: a summary

Background: This article summarizes the European Renal Association – European Dialysis and Transplant Association Registry’s 2014 annual report. It describes the epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in 2014 within 35 countries.

Methods: In 2016, the ERA-EDTA Registry received data on patients who in 2014 where undergoing RRT for ESRD, from 51 national or regional renal registries. Thirty-two registries provided individual patient level data and 19 provided aggregated patient level data. The incidence, prevalence and survival probabilities of these patients were determined.

Results: In 2014, 70 953 individuals commenced RRT for ESRD, equating to an overall unadjusted incidence rate of 133 per million population (pmp). The incidence ranged by 10-fold; from 23 pmp in the Ukraine to 237 pmp in Portugal. Of the patients commencing RRT, almost two-thirds were men, over half were aged ≥65 years and a quarter had diabetes mellitus as their primary renal diagnosis. By day 91 of commencing RRT, 81% of patients were receiving haemodialysis. On 31 December 2014, 490 743 individuals were receiving RRT for ESRD, equating to an unadjusted prevalence of 924 pmp. This ranged throughout Europe by more than 10-fold, from 157 pmp in the Ukraine to 1794 pmp in Portugal. In 2014, 19 406 kidney transplantations were performed, equating to an overall unadjusted transplant rate of 36 pmp. Again this varied considerably throughout Europe. For patients commencing RRT during 2005–09, the 5-year-adjusted patient survival probabilities on all RRT modalities was 63.3% (95% confidence interval 63.0–63.6). The expected remaining lifetime of a 20- to 24-year-old patient with ESRD receiving dialysis or living with a kidney transplant was 21.9 and 44.0 years, respectively. This was substantially lower than the 61.8 years of expected remaining lifetime of a 20-year-old patient without ESRD.

The Need for Accurate Risk Prediction Models for Road Mapping, Shared Decision Making and Care Planning for the Elderly with Advanced Chronic Kidney Disease

As people age, chronic kidney disease becomes more common, but it rarely leads to end-stage kidney disease. When it does, the choice between dialysis and conservative care can be daunting, as much depends on life expectancy and personal expectations of medical care. Shared decision making implies adequately informing patients about their options, and facilitating deliberation of the available information, such that decisions are tailored to the individual's values and preferences. Accurate estimations of one's risk of progression to end-stage kidney disease and death with or without dialysis are essential for shared decision making to be effective. Formal risk prediction models can help, provided they are externally validated, well-calibrated and discriminative; include unambiguous and measureable variables; and come with readily applicable equations or scores. Reliable, externally validated risk prediction models for progression of chronic kidney disease to end-stage kidney disease or mortality in frail elderly with or without chronic kidney disease are scant. Within this paper, we discuss a number of promising models, highlighting both the strengths and limitations physicians should understand for using them judiciously, and emphasize the need for external validation over new development for further advancing the field.

Early and Long-Term Outcomes of Kidney Grafts Procured From Multiple-Organ Donors and Kidney-Only Donors

BACKGROUND

The deceased-donor kidney pool consists of 2 different populations: multiple-organ donors (MOD) and kidney donors alone (KDA). In MOD, more complicated procedure and lowest priority for kidney procurement may affect graft survival. On the other hand, poor donor status and higher comorbidity are more frequent in KDA transplants. The aim of this study was to provide detailed characteristics of the 2 groups of kidney donors (KDA vs MOD) in our center and to analyze the potential influence of the donor type on the early and long-term kidney graft function and recipient outcome.

METHODS

We performed a retrospective analysis of 729 first cadaveric kidney transplant recipients: 499 of them received the organ from MOD, 230 from KDA.

RESULTS

The frequency of delayed graft function (DGF) was higher in KDA than in MOD transplants (38.7 vs 25.1%; P < .001). Multivariate logistic regression analysis revealed that donor age, KDA, and early acute rejection independently increased the risk of DGF occurrence, whereas recipient age and cold ischemia time increased the risk of primary graft nonfunction. Kidney excretory function was significantly worse in KDA up to 10 years after transplantation. There were no differences in kidney graft and patient survivals, frequency of proteinuria, acute rejection, and cytomegalovirus episodes, and post-transplantation diabetes.

CONCLUSIONS

(1) The use of a kidney from KDA negatively affects early and late kidney graft function compared with MOD. (2) The long-term kidney graft and patient survivals are not affected by the type of organ procurement.

Diabetes and disordered bone metabolism (diabetic osteodystrophy): time for recognition

Diabetes and osteoporosis are rapidly growing diseases. The link between the high fracture incidence in diabetes as compared with the non-diabetic state has recently been recognized. While this review cannot cover every aspect of diabetic osteodystrophy, it attempts to incorporate current information from the First International Symposium on Diabetes and Bone presentations in Rome in 2014. Diabetes and osteoporosis are fast-growing diseases in the western world and are becoming a major problem in the emerging economic nations. Aging of populations worldwide will be responsible for an increased risk in the incidence of osteoporosis and diabetes. Furthermore, the economic burden due to complications of these diseases is enormous and will continue to increase unless public awareness of these diseases, the curbing of obesity, and cost-effective measures are instituted. The link between diabetes and fractures being more common in diabetics than non-diabetics has been widely recognized. At the same time, many questions remain regarding the underlying mechanisms for greater bone fragility in diabetic patients and the best approach to risk assessment and treatment to prevent fractures. Although it cannot cover every aspect of diabetic osteodystrophy, this review will attempt to incorporate current information particularly from the First International Symposium on Diabetes and Bone presentations in Rome in November 2014.

Subtotal parathyroidectomy for secondary renal hyperparathyroidism: a 20-year surgical outcome study

Aim

The aim of this study was to evaluate the outcomes of surgery for patients with secondary renal hyperparathyroidism (rHPT).

Methods

This is a retrospective cohort study. Our institutional database was searched for eligible patients treated in 1995–2014. The inclusion criterion was initial parathyroidectomy for rHPT. Clinical and follow-up data were analyzed to estimate the cure rate (primary outcome), and morbidity (secondary outcome).

Results

The study group comprised 297 patients (154 females, age 44.5 ± 13.7 years, follow-up 24.6 ± 10.5 months), including 268 (90.2 %) patients who had underwent subtotal parathyroidectomy, and 29 (9.8 %) who had had incomplete parathyroidectomy. Intraoperative iPTH assay was utilized in 207 (69.7 %) explorations. Persistent rHPT occurred in 12/268 (4.5 %) patients after subtotal parathyroidectomy and 5/29 (17.2 %) subjects after incomplete parathyroidectomy (p = 0.005). The patients operated on with intraoperative iPTH assay had a higher cure rate than non-monitored individuals, 201/207 (97.1 %) vs. 79/90 (87.8 %), respectively (p = 0.001). In-hospital mortality occurred in 1/297 (0.3 %) patient. The hungry bone syndrome occurred in 84/268 (31.3 %) patients after subtotal parathyroidectomy and 2/29 (6.9 %) subjects after incomplete parathyroidectomy (p = 0.006). Transient recurrent laryngeal nerve paresis occurred in 14/594 (2.4 %) and permanent in 5/594 (0.8 %) nerves at risk.

Conclusions

Subtotal parathyroidectomy is a safe and efficacious treatment for patients with rHPT. Utilization of intraoperative iPTH assay can guide surgical exploration and improve the cure rate.

External Validation of a risk stratification model to assist shared decision making for patients starting renal replacement therapy

Background

Shared decision making is nowadays acknowledged as an essential step when deciding on starting renal replacement therapy. Valid risk stratification of prognosis is, besides discussing quality of life, crucial in this regard. We intended to validate a recently published risk stratification model in a large cohort of incident patients starting renal replacement therapy in Flanders.

Methods

During 3 years (2001–2003), the data set collected for the Nederlandstalige Belgische Vereniging voor Nefrologie (NBVN) registry was expanded with parameters of comorbidity. For all incident patients, the abbreviated REIN score(aREIN), being the REIN score without the parameter “mobility”, was calculated, and prognostication of mortality at 3, 6 and 12 month after start of renal replacement therapy (RRT) was evaluated.

Results

Three thousand four hundred seventy-two patients started RRT in Flanders during the observation period (mean age 67.6 ± 14.3, 56.7 % men, 33.6 % diabetes). The mean aREIN score was 4.1 ± 2.8, and 56.8, 23.1, 12.6 and 7.4 % of patients had a score of ≤4, 5–6, 7–8 or ≥9 respectively. Mortality at 3, 6 and 12 months was 8.6, 14.1 and 19.6 % in the overall and 13.2, 21.5 and 31.9 % in the group with age >75 respectively. In RoC analysis, the aREIN score had an AUC of 0.74 for prediction of survival at 3, 6 and 12 months. There was an incremental increase in mortality with the aREIN score from 5.6 to 45.8 % mortality at 6 months for those with a score ≤4 or ≥9 respectively.

Conclusion

The aREIN score is a useful tool to predict short term prognosis of patients starting renal replacement therapy as based on comorbidity and age, and delivers meaningful discrimination between low and high risk populations. As such, it can be a useful instrument to be incorporated in shared decision making on whether or not start of dialysis is worthwhile.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-016-0253-3) contains supplementary material, which is available to authorized users.

Special considerations for the treatment of chronic kidney disease in the elderly

Chronic kidney disease (CKD) is common in older adults, and its burden is expected to increase in older populations. Even if the knowledge on the approach to older patient with CKD is still evolving, current guidelines for pharmacological management of CKD does not include specific recommendations for older patients. Additionally, decision-making on renal replacement therapy (RRT) for older patients is far from being evidence-based, and despite the improvement in dialysis outcomes, RRT may cause more harm than benefit compared with conservative care when prognostic stratification is not carefully assessed. The use of comprehensive geriatric assessment tools could help clinicians in applying a more informed decision-making. Finally, physical exercise and rehabilitation interventions also represents a promising therapeutic strategy.

Kidney Transplantation Among the Elderly: Challenges and Opportunities to Improve Outcomes

Elderly patients (>65 years old) represent the fastest growing population among the ESRD patients and those awaiting kidney transplantation. There is ample evidence to suggest that kidney transplant in the elderly population offers the best chance of survival and improves health-related quality of life compared to remaining on dialysis. Although all these emerging facts are encouraging, this population brings with them complex medical problems including frailty, cognitive impairment, and multiple comorbidities. These issues can be barriers to transplantation and threaten the well-being of the patients after transplantation. Furthermore, aging results in changes to the immune system and affects the pharmacokinetics of immunosuppressants. All these changes can increase risk of complications such as infections and malignancy. Because death with a functioning graft is a common cause of graft loss, the new kidney allocation system has been implemented in an attempt to maximize allograft utilization and minimize unrealized graft years. This may result in longer wait-times for the elderly. In this review, we will highlight the barriers to kidney transplant, characterize transplant-related issues in the elderly, and propose alternative strategies under the new allocation system.

Reciprocating living kidney donor generosity: tax credits, health insurance and an outcomes registry

Kidney transplantation significantly improves patient survival, and is the most cost effective renal replacement option compared with dialysis therapy. Living kidney donors provide a valuable societal gift, but face many formidable disincentive barriers that include not only short- and long-term health risks, but also concerns regarding financial expenditures and health insurance. Other than governmental coverage for their medical evaluation and surgical expenses, donors are often asked to personally bear a significant financial responsibility due to lost work wages and travel expenses. In order to alleviate this economic burden for donors, we advocate for the consideration of tax credits, lifelong health insurance coverage, and an outcomes registry as societal reciprocity to reward their altruistic act of kidney donation.

Is There an 'Optimal Dose' of Hemodiafiltration?

BACKGROUND

Retrospective randomized clinical studies have shown that online hemodiafiltration (OL-HDF) is associated with a lower risk reduction of mortality than standard hemodialysis.

SUMMARY

In all of these large randomized studies, the convective volume seemed to be an important issue, but the optimal OL-HDF dose has not yet been defined. This article, to make a EUDIAL working group position, reviews the association between survival and convective volume, the minimum recommended replacement volume, the importance of the infusion flow rate, and the main limiting factors in achieving a high convective volume. Finally, the article discusses whether the convective dose should be normalized to body size. Key Messages: At present, there is sufficient scientific evidence to indicate that OL-HDF treatment reduces mortality risk and that it should be the first-line option in hemodialysis patients. It seems reasonable to recommend that patients should receive the highest possible convective dose and that the largest possible blood flow should be used to obtain the highest possible infusion flow rate. Based on the results of secondary analyses of the main clinical trials, the current recommendation of the optimal dose of OL-HDF, in the postdilutional mode and on a thrice-weekly treatment schedule, would be a convective volume higher than 23 liters/session. There is insufficient scientific evidence to recommend that the convective dose should be normalized to body size.

Comprehensive geriatric assessment: comparison of elderly hemodialysis patients and primary care patients

BACKGROUNDS

The quality of life and survival of elderly depend not only on their age but on many social and health factors. In the present study, comprehensive geriatric assessment (CGA) was made in elderly patients on regular hemodialysis (HD) and those without chronic kidney disease recruited in primary health care in order to compare their sociodemographic characteristics, physical health, functional ability and social support.

METHOD

The 106 HD patients and 300 primary care patients aged 70 years and more were studied. Data on sociodemographic characteristics, neurosensory deficits, pain, falls, polypharmacy, basic activities of daily living (ADL) questionnaire, instrumental activities of daily living (IADL) questionnaire were obtained during interview. The Timed Up and Go, Nutritional Health Checklist, Two Question Instrument for depression and Charlson comorbidity index (CCI) were applied.

RESULTS

No significant differences were found for age, gender, education level and dwelling between the two groups. A lower percentage of HD patients lived alone when compared with controls. BMI >25 kg/m(2) had 43.4% of HD patients and 49.3% of controls. CCI differed significantly between HD and primary care patients (median: 6 vs. 4) and significantly more HD patients reported depression. No significant difference was found between groups for cognitive dysfunction and ADL, but HD patients had significantly lower IADL scores than controls. The mobility of HD patients was worse; 45.7% of them reported falls in the previous year but only 9.7% from the controls.

CONCLUSIONS

CGA revealed that HD patients had significantly higher CCI, worse IADL score, mobility and reported more frequent falls, depression and impaired vision than primary care patients.

2012 ERA-EDTA Registry Annual Report: cautious optimism on outcomes, concern about persistent inequalities and data black-outs

The 2012 ERA-EDTA Registry Annual Report contains both good news and bad news. On the bright side, the 2-year survival of patients starting renal replacement therapy (RRT) for chronic kidney disease (CKD), on dialysis or receiving a living-related kidney transplantation, has progressively increased to 82.2, 79.7 and 98.3%, respectively, whereas for cadaveric kidney transplantation it remains stable (96.0-96.1%). On the dark side, inequalities persist between European citizens in access to renal transplantation and in incidence and prevalence of RRT. Living in Greece, Belgium (French- or Dutch-speaking) or Portugal (the GBP countries) is associated with higher chances of initiating RRT than living in other European countries. The adjusted RRT incidence for GBP countries was 188, 201-174 and 220* (* unadjusted) pmp in 2012, respectively (versus 122, 114 and 97 pmp in the Netherlands or two Spanish regions bordering Portugal). In lower income countries, a low RRT incidence may represent lack of access to needed healthcare (e.g. Montenegro 26 pmp). However, how can the high incidence and prevalence of RRT in the GBP countries be explained? Do GBP citizens have access to RRT that is denied, rejected or considered unnecessary in other high income countries? Does the GBP healthcare system fail to prevent progression of CKD? Do local genetic or environmental factors favour CKD progression? Unravelling the underlying reasons is an urgent research need: only an understanding of the causes will allow correction of the problem. Unavailability of data from some large countries (e.g. Germany and Italy) is not helpful.

End-stage renal disease and survival in people with diabetes: a national database linkage study

BACKGROUND

Increasing prevalence of diabetes worldwide is projected to lead to an increase in patients with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT).

AIM

To provide contemporary estimates of the prevalence of ESRD and requirement for RRT among people with diabetes in a nationwide study and to report associated survival.

METHODS

Data were extracted and linked from three national databases: Scottish Renal Registry, Scottish Care Initiative-Diabetes Collaboration and National Records of Scotland death data. Survival analyses were modelled with Cox regression.

RESULTS

Point prevalence of chronic kidney disease (CKD)5 in 2008 was 1.63% of 19 414 people with type 1 diabetes (T1DM) compared with 0.58% of 167 871 people with type 2 diabetes (T2DM) (odds ratio for DM type 0.97, P = 0.77, on adjustment for duration. Although 83% of those with T1DM and CKD5 and 61% of those with T2DM and CKD5 were receiving RRT, there was no difference when adjusted for age, sex and DM duration (odds ratio for DM type 0.83, P = 0.432). Diabetic nephropathy was the primary renal diagnosis in 91% of people with T1DM and 58% of people with T2DM on RRT. Median survival time from initiation of RRT was 3.84 years (95% CI 2.77, 4.62) in T1DM and 2.16 years (95% CI: 1.92, 2.38) in T2DM.

CONCLUSION

Considerable numbers of patients with diabetes continue to progress to CKD5 and RRT. Almost half of all RRT cases in T2DM are considered to be due to conditions other than diabetic nephropathy. Median survival time for people with diabetes from initiation of RRT remains poor. These prevalence data are important for future resource planning.

Anticipated increase in the number of patients who require dialysis treatment among the aging population of Japan

The aging population is anticipated to have a large impact on the number of incident dialysis patients, as the risk of end-stage kidney disease increases with age. This study aimed to examine trends in the sex- and age-specific incidence rates of dialysis between 2008 and 2012, and to assess the impact of population aging on the number of incident dialysis patients over the next decade in Japan. Incidence was calculated using published data and Japan's population statistics. The 2012 incidence was extrapolated, and projected future demographic changes within the Japanese population were used to estimate the number of incident dialysis patients in 2020 and 2025. As a general trend, the sex- and age-specific incidence rates of dialysis decreased gradually between 2008 and 2012, except among men aged ≥80 years. The total number of incident dialysis patients was projected to increase by 12.8% from 36 590 in 2012 to 41 270 in 2025. Greater increases were observed in the oldest age group (≥85 years). In 2025, the number of incident dialysis patients in this group was projected to increase by 92.6% in men and 62.2% in women. This study shows the number of patients who initiate dialysis treatment is projected to increase over the next decade in Japan due to aging of the population. Effective strategies are needed to offset the challenges faced by the aging population, with a particular focus on octogenarians and older, given the notable proportion of patients requiring dialysis treatment in the future.